Provider Demographics
NPI:1073170924
Name:MANCILLA-VILLA, CLAUDIA
Entity Type:Individual
Prefix:
First Name:CLAUDIA
Middle Name:
Last Name:MANCILLA-VILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 MORNINGSIDE ST # 300
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-1544
Mailing Address - Country:US
Mailing Address - Phone:541-499-2646
Mailing Address - Fax:
Practice Address - Street 1:1698 E MCANDREWS RD STE 300
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-5590
Practice Address - Country:US
Practice Address - Phone:541-732-7950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker